Analysis by William Laing, chairman of LaingBuisson, predicts 26,000 older care home residents in England will have died from Covid-19 and collateral damage by the end of May. Here he explains
On March 19, NHS England sent out a letter instructing NHS Trusts to free up capacity to make way for Covid-19 patients needing intensive care. ‘To do this we need to organise the safe and rapid discharge of those people who no longer need to be in a hospital bed. The new default will be discharge home today’, the letter said.
Faced with a threat of unknown scale, no-one could doubt the government was right to take radical action to scale down other hospital activity to achieve the primary goal. But since then, it seems, a law of unintended consequences has played out.
The main casualties can now be seen as older care home residents. Two charts based on deaths published by official sources tell the story very clearly. They relate to England, but the same story probably holds for the devolved administrations as well.
Most of the time, death rates are fairly steady and predictable. It’s what makes the life insurance business work.
The first chart shows how deaths during the early part of 2020 closely tracked the five-year (2015-19) average, mainly in the 10,000 – 12,000 per week band.
The first deaths from the Covid pandemic were recorded in March and rapidly accelerated in April. But the unexpected thing, which commentators immediately picked up on, was the fact that deaths attributed to Covid-19 (through a positive test or mentioned in death certificates) formed just part of the ‘excess’ deaths being recorded.
By the week ending April 17, the weekly death from toll from Covid had reached a peak of 8,335, including deaths in hospitals and the community. At the same time, other ‘excess’ deaths (i.e. deaths over and above the baseline and additional to Covid-19) also reached a peak, of 4,204.
To understand the full picture, it is essential to count the two together as being either directly or indirectly caused by Covid. In other words, about 12,500 deaths a week at its peak.
So, where did these other ‘excess’ deaths come from?
One obvious possibility is that Covid-19 was being under-recorded (false negatives).
There were plenty of anecdotal reports in support of this. But equally, there were anecdotal reports of false positives.
Another explanation was that people had become wary of seeking hospital treatment and failed to seek it when needed.
There may be some truth in that, and future mortality rates for cancer will certainly be scrutinised to see if there is a significant step up in cancer mortality in the coming months and years, as delayed treatment during the coronavirus emergency takes its longer-term toll.
But the next chart makes it crystal clear that the impact on the general population has been limited and that most non-Covid ‘excess’ deaths were in fact taking place among a small population of care home residents.
Because the first official statistics focused on NHS hospital deaths only, and did not include deaths in care homes and the community, a new data series was established by the Office for National Statistics from the week ending 17 April, based on deaths notified by care homes to the Care Quality Commission (CQC).
Because they are notifications rather than registrations there may be a small time lag between the two sets of statistics, but not sufficient to invalidate comparisons.
It is also important to note that death notifications to CQC include deaths of care home residents wherever they take place, including NHS hospitals.
The numbers, therefore, in principle represent the entirety of the care home death toll. The only caveat is that there may be some undercounting because some care home residents do not have their care home listed as their place of residence.
The key observation is that, for the week ending 17 April, when mortality hit its peak, the 2,713 non-Covid ‘excess’ deaths among care home residents accounted for the bulk (65%) of all (4,204) non-Covid ‘excess’ deaths across the population as a whole – see Chart 1.
What this means, if the explanation which follows is valid, is that care home residents suffered most of what may be called the ‘collateral damage’ arising as an unintended consequence of the March 19 decision to clear NHS hospital beds and focus on Covid.
At the peak of the crisis, there were widespread reports of normal medical support simply being removed from care homes.
Ambulances would not turn up to take emergencies to hospital, since capacity had to be kept clear for Covid cases. In-person GP house calls were replaced with occasional telephone calls.
In the absence of any expectation of active medical support, care home residents were encouraged to consider what instructions they should give in the case of serious illness from whatever cause, with many opting for DNR (do not resuscitate).
At the same time, care homes were being asked by NHS Trusts to accept discharges without knowing the coronavirus status of the patient concerned.
In the nature of the things, it is unlikely that the source of infection can be traced, but it is likely that hasty discharges were the port of entry of coronavirus into some care homes.
Meanwhile, shortages of PPE must have aided transmission.
The scenario described here – absence of normal medical care exacerbated by PPE shortages – is the only one that can satisfactorily explain the concentration of collateral damage (non-Covid ‘excess’ deaths) as well as Covid deaths within the care home population.
The pandemic is now on the wane. With information available up to 8 May, it looks as if Covid-related and non-Covid ‘excess’ deaths will be approaching zero by the end of May, following Farr’s law of a roughly symmetrical bell-shaped rise and fall in mortality.
If so, and assuming no second wave, the final death toll from Covid-19 and other ‘excess’ deaths combined looks likely to reach about 52,000, of which about half (26,000) will have been care home residents – nearly all of them living in older people’s care homes.
Before the coronavirus emergency there were 314,000 residents of older people’s care homes in England.
That figure will have fallen to about 288,000 by the end of May, mitigated by whatever new admissions are taking place. There is no central collection of new admissions, so the net fall will probably not be transparent.
Severe cost pressures are likely to remain long after excess mortality has worked its way through. PPE will remain in use, if only as a precaution, for several months to come.
It will also take time for vulnerable older people and their families to regain confidence in care homes as safe places, and demand for substitutes such as live-in homecare and housing with care will be boosted.
Over 90% of older people’s care home capacity is now in the hands of independent sector providers, mainly for-profit. The whole sector will be under intense financial pressure in the coming months, not only from loss of income as a result of reduced occupancy but also the massive costs of PPE.
To some providers the threat is existential. Care home operators will join the long list of businesses looking to the government for financial support. To date, the government has pledged £3.2bn to help local authorities to cover Covid costs, but this is for all council services, not just social care.
Some of it is now filtering through to care services, but it looks certain that the care home sector will be looking for substantially more financial support from the government than is on the table now.